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Gifts, Memorials, and Tributes
Select Gift Frequency
I would like to make a one-time gift for the following amount:
:* $
I would like to make a recurring gift.
Gift Amount* # of Payments Payment Frequency Total Gift Amount
$ X = $
NOTE: This transaction will count as the first payment toward your total gift amount.
Area you wish to support:
Select the area that you wish to support*
 
Donor Information
Title:*
First Name:*
Middle Initial:
Last Name:*
Suffix:
Please list how your gift should be acknowledged:
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Phone:*
Email:*
I would like to this gift to be anonymous: Yes
No
Are you a Memorial Health Team Member and/or Physician?:*
Would you like this gift to be recognized during the 2013-2014 My Memorial Team Member Giving campaign?:
Payment Information
Payment Method
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Credit Card Type:*
Credit Card Expiration:*
Billing Information
If the billing information is the same as the contact information check this box.
If not please fill out the information below:
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State:
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Country:*
Matching Gift Information
Will this donation be potentially matched?
If you know the following information regarding the matching gift, please complete.
Company Name:
Matching Gift Amount:$
Additional Information
This gift is in honor or memory of someone special: In honor of:
In memory of:
Full Name:
Mail a letter on my behalf to the following person: Yes
Notificant Full Name:
Acknowledgee Address:
Acknowledgee City:
Acknowledgee State:
Acknowledgee Zip Code:
Please contact me about providing a gift to Memorial Health Foundation in my will or estate plan: Yes
No
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